Provider Demographics
NPI:1457378804
Name:ALLIANCE FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:ALLIANCE FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALFREDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-323-5575
Mailing Address - Street 1:3333 S CRATER RD
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9276
Mailing Address - Country:US
Mailing Address - Phone:804-733-3438
Mailing Address - Fax:804-733-7424
Practice Address - Street 1:3333 S CRATER RD
Practice Address - Street 2:SUITE 3A
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9276
Practice Address - Country:US
Practice Address - Phone:804-733-3438
Practice Address - Fax:804-733-7424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024131004363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024131004OtherSTATE ID
VA0024131004OtherSTATE ID